The Use of Operating Theatres in the Northern Ireland Health and Personal Social Services (HC 1227-i) Public Accounts Committee 2 Nov 2004

Evidence given by Mr Clive Gowdy CB, Permanent Secretary and Accounting Officer, Dr Ian Carson, Deputy Chief Medical Officer, and Mr Andrew Hamilton, Deputy Secretary, Primary, Secondary and Community Care Group, Northern Ireland Department of Health, Social Services and Public Safety.

Q30 Mr. Gerry Steinberg (City of Durham): Thank you, Chairman. Mr Gowdy, 37% is quite a remarkable figure really when you consider that theatres are standing empty almost 40% of the time, in fact it could be 40%, could it not, because this 37% could be a lot worse, could it not?

Mr Gowdy: It is a point I was making at the start, that there are variations in terms of the nature of hospitals.

Q31 Mr. Gerry Steinberg (City of Durham): It could be more than 37%.

Mr Gowdy: In some cases it is definitely more than 37%.

Q32 Mr. Gerry Steinberg (City of Durham): I cannot believe that.

Mr Gowdy: What you need to appreciate is that some of the theatres are used for emergency use exclusively.

Q33 Mr. Gerry Steinberg (City of Durham): You have explained that. Tell us some basic facts. Tell us, how long are the theatres open each day?

Mr Gowdy: Primarily they are open two sessions each day for five days a week. That is a morning session and ---

Q34 Mr. Gerry Steinberg (City of Durham): How long is a session?

Dr Carson: Three and a half hours was the traditional scheduled sessional commitment for a hospital consultant, a notional half day.

Q35 Mr. Gerry Steinberg (City of Durham): Ah, here they come, the hospital consultants. So after three and a half hours, "Stitch him up lads, we are finished. We will go home for the day".

Mr Gowdy: There are a couple of points that need to be made here. One is that operations can be estimated but not predicted. There is a range of circumstances. A patient may need a more difficult operation.

Q36 Mr. Gerry Steinberg (City of Durham): I understand. So it is open three and a half hours in the morning and three and a half hours in the afternoon, seven hours a day. How many hours are there in a day?

Dr Carson: I could illustrate a normal working day for myself when I was a consultant anaesthetist in the cardiac surgical unit, if that would help.

Q37 Mr. Gerry Steinberg (City of Durham): No, I would only lose my temper because you would probably substantiate what I think. How many days a week are they open?

Mr Gowdy: What we are dealing with here is ----

Q38 Mr. Gerry Steinberg (City of Durham): How many days a week are they open?

Mr Gowdy: Five days a week. There are also sessions used at the weekends and in the evenings for emergency sessions.

Q39 Mr. Gerry Steinberg (City of Durham): We are going to get on to that.

Mr Gowdy: Or where we have been able to put in additional resources to allow that to happen.

Q40 Mr. Gerry Steinberg (City of Durham): So they are open seven hours a day, five days a week and possibly at the weekends. How much money have you actually had in real terms increase in the last four to five years?

Mr Gowdy: In our overall budget?

Q41 Mr. Gerry Steinberg (City of Durham): Yes.

Mr Gowdy: Mr Hamilton would be in a better position to deal with that. Can I just say to you very quickly that it is not a case of us not being able to run the theatres continuously from the earliest hours in the morning through to the latest hours at night but between each session the theatres need to be cleaned and any of the consumables that are used need to be put in place.

Q42 Mr. Gerry Steinberg (City of Durham): A friend of mine is in the local hospital, my wife went to visit them on Sunday, and the operating theatres were being used at six o'clock on Sunday night for routine operations. Does that happen in Northern Ireland?

Mr Gowdy: It has happened on occasions when we ----

Q43 Mr. Gerry Steinberg (City of Durham): I am not talking about on occasions, does it happen?

Mr Gowdy: Not with the level of funding we have got.

Q44 Mr. Gerry Steinberg (City of Durham): So how much real term increase have you had?

Mr Hamilton: Over the last few years in real terms increase for service development we have had about 30 to 40 million a year.

Q45 Mr. Gerry Steinberg (City of Durham): Extra?

Mr Hamilton: Extra.

Q46 Mr. Gerry Steinberg (City of Durham): What are you doing with it?

Mr Hamilton: That has been used to invest across a whole range of services right across from the community to life saving interventions.

Mr Gowdy: The introduction of new drugs.

Q47 Mr. Gerry Steinberg (City of Durham): How many more operations have taken place since you have had the increase in resources?

Mr Hamilton: We have funded 2,500 additional sessions since the last report. That is additionality, additional sessions.

Q48 Mr. Gerry Steinberg (City of Durham): So what was it before then? What was the capacity being used before that? If it is 37% now it must have been, what, around 15%?

Mr Gowdy: It has moved up. The figures that are in the report relate to the 63%, something in the order of 30,500 sessions held in our theatres. In 2003-04 that had risen to 33,052 sessions which equates to a 64% utilisation. The point I was making earlier was we have aspirations to increase but it is not possible to make quantum jumps.

Q49 Mr. Gerry Steinberg (City of Durham): Tell me, do you use the theatres for private operations?

Mr Gowdy: Pardon?

Q50 Mr. Gerry Steinberg (City of Durham): Do the surgeons use the theatres for private operations?

Dr Carson: The private sector in Northern Ireland is very small. The majority of that private sector work is done in the independent hospital sector.

Q51 Mr. Gerry Steinberg (City of Durham): You are not answering the question.

Dr Carson: There are some situations where private patients are done within NHS facilities, that is correct.

Q52 Mr. Gerry Steinberg (City of Durham): When do they use the theatres?

Dr Carson: Those theatres may be set aside specifically for private sector time.

Q53 Mr. Gerry Steinberg (City of Durham): So you are telling us that NHS theatres are being used for the private sector and 37% of the theatres stand empty at some stage during the year and private medicine and private operations are taking place during that 37%?

Dr Carson: Private sector medicine is not displacing NHS activity.

Q54 Mr. Gerry Steinberg (City of Durham): It must be.

Dr Carson: No, it is not.

Mr Gowdy: If we had no funding we would put money in.

Q55 Mr. Gerry Steinberg (City of Durham): How much are consultants allowed to earn on top of their contracted wage in the private sector? Is it the same as in England?

Dr Carson: It is no different from England.

Q56 Mr. Gerry Steinberg (City of Durham): 10%?

Dr Carson: There is no limit on what a consultant surgeon can earn in the private sector, no limit.

Q57 Mr. Gerry Steinberg (City of Durham): Yes, there is a limit, 10% of their salary.

Dr Carson: That is if you wish to retain the full terms and conditions of an NHS contract, but there are others who work outside that and beyond that.

Q58 Mr. Gerry Steinberg (City of Durham): I got a statistic yesterday - I am not going to tell you where it came from - that was quite amazing. I was told yesterday that some of the private consultants in Northern Ireland are earning £40,000 a year extra. No, a month extra. £40,000 a month extra to boost their salaries. If they are doing that they must be doing a hell of a lot of private work that could have been done on the NHS. Am I right or wrong?

Mr Gowdy: There is a very small proportion, as Dr Carson said ----

Q59 Mr. Gerry Steinberg (City of Durham): I am asking Dr Carson.

Dr Carson: I want to reinforce the fact that we have a very small private sector in comparison with that which takes place in England.

Q60 Mr. Gerry Steinberg (City of Durham): I do not know about that. I know there are not many surgeons in England earning £40,000 a month, whether it is a big one or a little one.

Dr Carson: The vast majority of that private sector work takes place outwith the health service facilities in the private independent sector.

Q61 Mr. Gerry Steinberg (City of Durham): But you did say some of it was taking place?

Dr Carson: Some of it takes place, yes.

Q62 Mr. Gerry Steinberg (City of Durham): We will leave that to the imagination.

Mr Gowdy: The point is it is not displacing NHS, HPSS.

Q63 Mr. Gerry Steinberg (City of Durham): Let us change the subject. Why are the theatres not utilised at weekends?

Mr Gowdy: There are a couple of reasons for that. One is that patients do not really like to be treated outside ----

Q64 Mr. Gerry Steinberg (City of Durham): Oh, come on, it is absolute poppycock that patients do not like to be treated on a Saturday.

Mr Gowdy: We could not run our theatres as intensively as you are suggesting outside normal hours.

Q65 Mr. Gerry Steinberg (City of Durham): Why not?

Mr Gowdy: The difficulties are ----

Q66 Mr. Gerry Steinberg (City of Durham): Tell the truth.

Mr Gowdy: The difficulties are getting staff and having the resources to fund them. As we said earlier, we are getting a very high utilisation ----

Q67 Mr. Gerry Steinberg (City of Durham): Because the consultants will not come in and do the work.

Mr Gowdy: May I put this point first because it is an important point to make. We are getting a very high utilisation out of the sessions that we are able to fund so that our trusts are delivering for us very close to 100% of all of the sessions that we have asked them to put in place.

Q68 Mr. Gerry Steinberg (City of Durham): If that is the case then you are at fault because you should be asking them to do more quite frankly, Mr Gowdy.

Mr Gowdy: We are trying to stretch them to do that. As I was saying earlier, we have actually seen some progress made in the couple of years since this report was published and we are trying to stretch beyond that.

Q69 Mr. Gerry Steinberg (City of Durham): Your theatres are being used for seven hours a day, five days a week. There is a huge capacity there that could be used but is not being used.

Mr Gowdy: Because we cannot fund it and we cannot staff it.

Mr. Gerry Steinberg (City of Durham): Let me just move on. Can you turn to page 104, please. I see here the annual leave of consultants stops a considerable number of operations taking place. I find that remarkable because when I take my summer holidays I usually organise them at least eight or nine months before we go. My wife - she has not quite mastered the Internet yet - goes to the travel agent and she books a holiday. It seems to me what happens in Northern Ireland is the consultant goes down to his breakfast one morning and the wife says, "We are off to Benidorm", is that right?

Chairman: He could probably afford to go to somewhere better than Benidorm.

Q70 Mr. Gerry Steinberg (City of Durham): You are right. "Just ring in and tell the lads that we will not be in today because we are off to Benidorm", that is what seems to happen here.

Dr Carson: Leave entitlement for an NHS consultant here is no different from what it is elsewhere in the UK.

Q71 Mr. Gerry Steinberg (City of Durham): I am not saying it is.

Dr Carson: This document, when it looked at availability of operating theatres, considered that 48 weeks was a normal average. In fact, a consultant ----

Q72 Mr. Gerry Steinberg (City of Durham): I have got no problem with that.

Dr Carson: A consultant is only available for 42 weeks of the year.

Q73 Mr. Gerry Steinberg (City of Durham): I have got no problem with that. The problem I have is that if it is done properly it is managed properly. If eight months beforehand, or seven months, six months, five months or four months beforehand, the surgeon says to the manager of the hospital, "I am off to Benidorm for a fortnight", therefore the cover will be brought in. I get the impression here that about 24 hours before the operation is supposed to take place, he rings in to say, "I am off for a fortnight's holiday".

Dr Carson: I would want to assure you that through the new arrangements in regard to theatre management such an opportunity should not and could not arise, and would be penalised within effective theatre management arrangements currently.

Q74 Mr. Gerry Steinberg (City of Durham): I am running out of time but I wanted to make the point that I was very, very cross when I read that. I understand that but if an operation is cancelled in the UK, in England, at the last minute, and they are regularly, which is a disgrace because people get hyped up for their operation and go in and an hour beforehand are told "On your bike, go home, we have not got this, that or the other to do the operation", they are guaranteed within 28 days to have that operation but in Northern Ireland they are not. That is quite outrageous. Why does that happen?

Mr Gowdy: We cannot fund that given the waiting list problems that we have got. The way to attack it is exactly the point you are making. What we need to do is to make sure that the management of leave arrangements is sharper. I think this is one of the virtues of this report. It has certainly drawn out for us a very clear need to get those arrangements in place. Some hospitals are now doing that, Craigavon Hospital tries to arrange evening sessions.

Q75 Mr. Gerry Steinberg (City of Durham): They should all be doing it.

Mr Gowdy: People will take leave for all sorts of reasons that come up at fairly short notice. What we need to do is to make sure we manage the totality of that and get the majority of leave notified sufficiently so that it does not affect the running of the sessions. I very much take your point on that.

Q76 Chairman: I want to be entirely fair to you, Dr Carson, you are obviously itching to tell Mr Steinberg your typical day. If you remember, there was not time to answer that question. Please give us, not the hardest working day or the least working day but an average day for you or your colleagues.

Dr Carson: When I was working in the cardiac surgical unit on a normal scheduled operating session I would be in the anaesthetic room seeing the first patient in the morning at 7.30. The patient would be anaesthetised and in the operating theatre at eight o'clock. The operation would last five hours, which would take you through to one o'clock. The second patient would arrive in the operating theatre at about half past one. I would quite often work on through with a minimal stop for lunch, if any at all. The patient would be anaesthetised and on the operating table at two o'clock. The operation would last for five hours and finish at seven o'clock. The patient would end up in the intensive care unit where I would discharge that patient over to the care of my intensive care colleagues at about seven o'clock in the evening. I would then go and see my patient for the next day and do all the other additional things that ---

Q77 Mr. Gerry Steinberg (City of Durham): It is a great pity that the rest of your colleagues are not doing the same, I have to say.

Mr Hamilton: I would be the first person to defend those colleagues who I know work very hard throughout the health service. We are on record as saying that consultants work over and above what they are by and large contracted to do. In England, where you are trying to introduce the new consultant contract, the Department is being challenged by consultants who are looking for 12, 13 and 14 programmed activities to cover the work they are currently doing. We are trying to introduce a consultant contract here within a financial envelope for a consultant that will deliver only ten programmed activities a week.

Mr. Gerry Steinberg (City of Durham): I wish you success.

This is an uncorrected transcript of evidence taken in public and reported to the House. The transcript has been placed on the internet on the authority of the Committee. Neither witnesses nor Members have had the opportunity to correct the record. The transcript is not yet an approved formal record of these proceedings.